Journal of Cardiovascular Nursing

Vol. 29, No. 6, pp 517Y527 x Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Family Context Influences Psychological Outcomes of Depressive Symptoms and Emotional Quality of Life in Patients With Heart Failure Kelly D. Stamp, PhD, ANP-C, RN; Sandra B. Dunbar, RN, DSN, FAHA, FAAN; Patricia C. Clark, PhD, RN, FAHA, FAAN; Carolyn M. Reilly, PhD, RN, FAHA; Rebecca A. Gary, PhD, RN, FAHA, FAAN; Melinda Higgins, PhD; Nadine Kaslow, PhD Background: Although family influences in heart failure (HF) care are considered important, little evidence is available regarding relationships between the family context and specific outcomes for patients with HF. Objective: The aim of this study was to examine the relationships of patient perceptions of family functioning, autonomy support, and perceived criticism, as well as their family member’s (FM) HF knowledge, with patient outcomes of depressive symptoms and HF quality of life (QOL). Methods: Participants (n = 117) with HF were enrolled in a family partnership intervention study. Self-report questionnaires measuring the HF patient’s perceptions of family context and the FM’s knowledge were analyzed relative to the HF patient’s outcomes using correlations and sequential multivariate regression analyses. Only preintervention, baseline data are reported here. Results: Age, ethnicity, Charlson comorbidity index, global family functioning, and FM’s HF knowledge accounted for 37.8% (P G .001) of the variance in the patient’s depressive symptoms. An additional moderating effect of ethnicity on the association between global family functioning and patient’s depressive symptoms was significant (change R2 = 0.06, P = .001), resulting in a final model that accounted for 43.3% of depressive symptom variance. Age, ethnicity, global family functioning, and autonomy support accounted for 24.9% (P G .001) of the variance in emotional HF QOL. An additional moderating effect of ethnicity on the association between global family functioning and patient’s emotional HF QOL was significant (change R2 = 0.05, P = .009), resulting in a final model that accounted for 28.9% of emotional QOL variance. Conclusions: This study underscores the importance of the patient’s perspective on family functioning and autonomy support, along with FM’s HF knowledge, on HF patient outcomes moderated by ethnicity. Future interventions could target the modifiable patient-family context relationships for improving depressive symptoms and QOL in HF patients. These findings point to the need for greater family assessment to identify those at risk for worse outcomes and to guide family focused interventions. KEY WORDS:

depressive symptoms, family context, heart failure, quality of life Nadine Kaslow, PhD

Kelly D. Stamp, PhD, ANP-C, RN

Professor, School of Medicine, Emory University, Atlanta, Georgia.

Assistant Professor, School of Nursing, Boston College, Chestnut Hill, Massachusetts.

This study was supported by ‘‘A Family Partnership Intervention for Heart Failure’’ (RO1 R08800), National Institute of Nursing Research, NIH 07/01/04-11/30/09 (principal investigator: S. Dunbar), and in part by PHS Grant M01 RR0039 from the General Clinical Research Center program, National Institutes of Health, National Center for Research Resources, and PHS Grant UL1 RR025008 from the Clinical and Translational Science Award program, National Institutes of Health, National Center for Research Resources, and the Atlanta Veterans Administration Medical Center. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Sandra B. Dunbar, RN, DSN, FAHA, FAAN Charles Howard Candler Professor of Cardiovascular Nursing, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.

Patricia C. Clark, PhD, RN, FAHA, FAAN Professor, Byrdine F. Lewis School of Nursing, Georgia State University, Atlanta.

Carolyn M. Reilly, PhD, RN, FAHA Assistant Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.

Rebecca A. Gary, PhD, RN, FAHA, FAAN Associate Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.

Melinda Higgins, PhD Associate Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.

The authors have no conflicts of interest to disclose.

Correspondence Kelly D. Stamp, PhD, ANP-C, RN, 140 Commonwealth Avenue, School of Nursing, Boston College, Cushing Hall 307, Chestnut Hill, MA 02467 ([email protected]). DOI: 10.1097/JCN.0000000000000097

517 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

518 Journal of Cardiovascular Nursing x November/December 2014

T

he incidence and prevalence of heart failure (HF) have become a major public health problem in the United States. Currently, 5.7 million Americans have a diagnosis of HF, and an additional 670 000 cases are diagnosed each year.1 The incidence of this disease is increasing at epidemic proportions, and the impact of HF is taking a tremendous toll on the quality of life (QOL) of patients with HF and their family members (FMs).1 Most recent estimates place HF incidence at 10 per 1000 population after age 65 years, with an equal lifetime risk of developing HF for both men and women at 1 in 5.2 Although family education and counseling are important, the way a family functions and communicates may also be key. The term family functioning has been defined as the ability of the family and patient to adapt, especially in the setting of chronic illness, and specific aspects of family functioning include problem solving and communication.3 Consequently, when family functioning is not optimal, the effects on a patient’s level of depressive symptoms and QOL outcomes may be affected.3 The literature regarding the effect of family functioning on levels of depressive symptoms in individuals with HF is limited. However, previous research has reported that spouse or FM caregivers with negative problem-solving abilities increase the levels of depression in HF patients, and this is similar in other chronically ill populations.4,5 Moreover, ineffective family functioning and communication exhibited by FMs through judgmental verbal or nonverbal behaviors may increase the chronically ill patient’s level of depressive symptoms.6 In addition, individuals with HF have reported lower levels of QOL compared with patients with other types of chronic illnesses.7 The symptom burden and complex treatment regimens require patients with HF and their FMs to make moderate to major lifestyle changes, which can affect their overall QOL.8 Variables that are reported to reduce QOL in individuals with HF are functional status, symptom burden, levels of depression, and social/family support.4,6,7,9Y12 Moreover, ethnicity may play a role in the level of QOL and family functioning. There is scant literature in this area; however, it has been reported that the presence of effective family functioning has had positive effects on African American (AA) and Mexican American adolescents’ attitudes compared with those of adolescents who experience ineffective family functioning.13 However, at this time, it is unclear how ethnicity and family function affect the perception of QOL in a chronically ill individual (ie, patient with HF). Family members can provide support through autonomy support, which was derived from the Selfdetermination Theory.3,14 Autonomy support occurs when FMs provide encouragement, empathy, and a sense of choice for patients. Thus, patients with HF can engage in their care regimen according to their perception

of importance and choice instead of adhering to their prescribed regimen because of controlling demands or threats from an FM or health provider.3,14 Research has shown that patients with other chronic conditions that lacked autonomy support were less successful with adhering to their care regimen or making behavior change.15Y18 The opposite of autonomy support is perceived criticism, which can occur when patients perceive a level of judgment and pressure with little acceptance of their feelings, thoughts, and decisions regarding how they choose to care for their chronic illness.19,20 In addition, knowledge is an important and foundational element for maintenance and management of the disease and is needed to empower patients with HF and their FMs.21 There is clear evidence that patients with HF and their FMs exhibit low levels of knowledge regarding their HF care regimen.22,23 Furthermore, education and counseling programs for patients with HF and their FMs have improved outcomes such as better adherence to a low-sodium diet, daily weights, medication adherence, and a decrease in rehospitalizations.3,14,24 Family member knowledge about HF is important to assist with and promote patient self-care; thus, it represents an important component of family context, but little is known about its impact on other outcomes such as depressive symptoms and QOL of the patient with HF. A better understanding of the relationship of family context to outcomes for patients with HF is important for the design and testing of successful family-focused interventions that may improve patient’s depressive symptoms and QOL outcomes. The purpose of this study was to examine the relationships of patient perceptions of family functioning, autonomy support, and perceived criticism, as well as the FM’s HF knowledge, with patient outcomes of depressive symptoms and QOL. We hypothesized that patients who perceived better family functioning, greater autonomy support, lower family criticism, and greater FM knowledge, when controlling for selected demographic variables including gender, ethnicity, age, education, and New York Heart Association (NYHA) functional class and other comorbidities, would report lower levels of depressive symptoms and better QOL.

Materials and Methods Design This was a descriptive study using baseline data from a family partner intervention study.14,24 Only baseline data collected from the patient before intervention are reported in this analysis of family context (family functioning, level of family knowledge, autonomy support, perceived criticism) and patient outcomes (depressive symptoms and QOL).

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Depression and Emotional QOL in Patients With HF 519

Sample The sample consisted of patients with HF and their FMs (N = 117 dyads) who were recruited from 3 large medical centers in the southeastern United States that had outpatient HF clinics. Inclusion criteria for patients with HF were (1) diagnosis of HF per echocardiogram report, NYHA class II to III per medical record, (2) aged 30 to 79 years, (3) ability to read, write, and speak English, (4) telephone access, (5) on medication regimens that included angiotensin converting enzyme inhibitors or angiotensin II receptor blockade, "-blocker, and diuretics unless contraindicated, (6) ambulatory, (7) glomerular filtration rate greater than 30, and (8) availability of a participating FM who assisted with the HF self-care (ie, interacted with the patient at least 2Y3 times per week). Items 1, 5, and 7 were verified from the medical record. Exclusion criteria for patients with HF consisted of (1) NYHA class I or IV determined by the medical record, (2) myocardial infarction within the last 6 months, (3) unstable angina, (4) renal failure, (5) impaired cognition, (6) psychiatric diagnosis of schizophrenia, dementia, or any other psychiatric illness that would impair their ability to participate, (7) HF secondary to a medical condition, (8) planned cardiac surgery, or (9) uncorrected visual or hearing problems. Items 1 through 8 were verified from the medical record. Family members had to be at least 19 years of age and have no evidence of conditions that would impair their ability to participate if randomized in the intervention sessions, such as impaired cognition or psychiatric diagnosis. Family members also had to interact routinely with the patient regarding their HF self-care 2 to 3 times a week. Measures Baseline demographic and clinical characteristics (age, gender, relationship to the participant with HF, marital status, comorbidities, and education) for participants with HF and their FMs were collected by self-report questionnaires and information derived from the patient’s medical record. The Charlson comorbidity index (CCI) score was calculated as a measure of the presence (weighted sum) of other comorbidities.25 Family Context Variables Family Functioning. The Family Assessment Device Questionnaire (FAD) is based on the McMaster Model of Family Functioning, which is used to conceptualize the organization of families and their interactions.26 This tool has been validated to distinguish between healthy and unhealthy family interactions. Three subscales of the FAD27 were used to measure the patient’s perceived level of family functioning. This included a total of 27 items, and the 3 subscales used were global family functioning (12 items), problem solving (6 items), and

communication (9 items). The global family functioning subscale assesses the overall health of the family, the problem solving subscale assesses the ability of the family to solve problems at a level that will maintain effective family functioning, and the communication subscale assesses how FMs exchange information among each other.26 The final mean score for global family functioning, problem solving, and communication ranges from 1 to 4 (healthy family functioning to unhealthy family functioning). In this study, the Cronbach’s ! for each subscale reflecting internal consistency reliability was .90 for the global family functioning, .85 for problem solving, and .72 for communication. Standard cut scores for each subscale (2.0 for global family functioning and 2.2 for problem solving and communication) were used to determine the percentage in the highest and lowest category for family functioning.26,28 A higher family function variable score on this instrument indicates less healthy family functioning. Autonomy Support. The Family Care Climate QuestionnaireYPatient Version (FCCQ-P) was used to measure the patient’s perceived autonomy support of the FM participating in the study.29 This is a 14-item Likert-type scale that addresses the amount of perceived support regarding lifestyle changes associated with their HF self-care and their interactions with the participating FM about these lifestyle changes. The FCCQ-P questions are focused on the patient’s perceptions of how much acceptance and support they have experienced regarding their choice of HF care behaviors, how open and communicative they can be with their FM about their care decisions and disease process, and the level of trust within the patient-FM relationship. The range for the final scores are from 1 to 7 (not true at all to very true), with higher scores indicating greater amounts of FM autonomy support perceived by the patient concerning their HF self-care management. The original version of the FCCQ-P has established reliability and validity (Cronbach’s ! = .89),29 which was .85 in the current study. Perceived Family Criticism. Perceived family criticism (PFC) was measured by the PFC scale of the Family Emotional Involvement and Criticism Scale (FEICS-PC).19 This scale measures general criticism from the family, which is viewed as the opposite to autonomy support, and it consists of 7 items scored on a 5-point Likerttype scale from 1 to 5 (1 = almost never to 5 = almost always). The average score ranges from 1 to 5, with higher scores representing higher perceived criticism from the family in general. The original version of the FEICS has reported adequate reliability coefficients of .82,30 and Cronbach’s ! was .82 in the current study. Heart Failure Knowledge Heart Failure Knowledge. The Atlanta Heart Failure Knowledge Test (AHFKT) was used to measure the FM’s

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520 Journal of Cardiovascular Nursing x November/December 2014 level of knowledge regarding HF.22 The AHFKT is a 27-item questionnaire that tests knowledge regarding the pathophysiology, dietary self-care, symptom assessment, and medication-taking behaviors for HF. The sum of the scores ranges from 0 to 27 and can be converted to a 0% to 100% scale The percentage correct was used in this study. Higher scores represent higher knowledge regarding HF self-care. Content and construct validity has been established with good internal consistency reliability for this cohort (Cronbach’s ! of .84).22 Outcome Measures Depressive Symptoms. Depressive symptoms were measured with the Beck Depression Inventory-II (BDI-II).31 The BDI-II is a well-established measure of depression, with 21 items representing such feelings as sadness, guilt, self-criticism, crying, and pessimism, for example. These items are rated on a scale of 0 to 3 to the degree in which the symptoms were experienced in the past 2 weeks. Total scores range from 0 to 63, with 14 or higher indicating the presence of depressive symptoms. Cronbach’s ! in this study was .92, which indicates acceptable internal consistency reliability. Quality of Life. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used to measure the patient’s perceived QOL.32 This tool is a selfassessment of how HF affects the patient’s daily life. It is a 21-item Likert-type measure with an overall score based on 2 dimensions (physical and emotional). A total score can also be obtained. Possible total scores for the emotional component range from 0 to 25; for the physical component, 0 to 40; and for the total component, 0 to 105. Cronbach’s ! in this study for the physical subscale was .91 (8 items) and the emotional subscale was .88 (5 items), and the total Cronbach’s ! was .92 for all 21 items. Higher scores represent a worse perceived QOL. Data Analysis Descriptive statistics were used to describe the sample and evaluate underlying distribution assumptions and missing data. To assess potential multicollinearity and confounding, Pearson correlations were run between and among the patient’s characteristics, perceptions of their family context, and outcomes of depressive symptoms and HF QOL. The only FM variables included in these analyses were the FM’s relationship to the patient and FM’s HF knowledge. Although data were collected on the FMs, the primary outcomes and focus of this study were the impact of the family context from the HF patients’ perspectives. As such, no dyadic (joint patient-FM) statistical models were used. Sequential (hierarchical) linear regression was used to build models for assessing the relationships between (block 2) patient perceptions of family context (FAD

scales for global family functioning, problem solving, and communication; autonomy support; and FM’s HF knowledge) and patient’s depressive symptoms (BDI-II total) and HF QOL (MLHFQ total, physical, and emotional scores) after adjusting for patient characteristics (age, gender, ethnicity, education, NYHA functional class, FM’s relationship to the patient, and the CCI) (block 1). Multicollinearity model assumptions were checked for condition index less than 30, variance inflation factors (VIFs) less than 2, and tolerance levels greater than 0.5. With all variables entered into the models, multicollinearity was evident, so the stepwise (SPSS SYNTAX/METHOD = STEPWISE) variable selection method (P G .05 for variable entry, P 9 .10 for removal) was used within each block to optimize each final model. To check the covariates for the regression assumption of homogeneity of slopes, all possible pairwise (2-way) interactions between the independent variables in each model were assessed for significance, which would challenge the homogeneity of slopes assumption. Only 1 significant interaction was found (ethnicity and family functioning), which was added to the model in an additional step (block 3) to complete each regression model. SPSS v.20 was used for all analyses.

Results Sample Characteristics As presented in Table 1, participants were middle aged, with slightly half being AA and most of the sample classified as having NYHA class II HF. Patients had several comorbidities, on average, with CCI scores ranging from 1 to 14. Most of the sample was fairly well educated, with almost half having some college education. On average, FMs were middle aged and predominately women and more than half were spouses. The FMs were also significantly younger (3.7 years on average) than the HF patients (P = .001). In addition, AA HF patients were significantly younger (mean [SD], 53.25 [10.5] years) than white HF patients (mean [SD], 59.57 [9.3] years; P = .001). The patient-perceived autonomy support scores (FCCQ-P) were relatively high (Table 2). Patient scores on the FAD indicated, on average, that they perceived their family functioning to be effective (lower scores indicated healthier family functioning). On average, patient PFC scores were low, as reflected by the mean FEICS scores. The FM HF knowledge was moderately low, with average AHFKT scores of 68% (Table 2). Average patient depressive symptom scores were below the clinical mild depression level of 14 (Table 2). The average MLHFQ QOL scores were in the middle of the range for the total scores and the physical subscale scores. However, the average emotional subscale scores for the MLHFQ of 9.65 were less than the scale’s

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Depression and Emotional QOL in Patients With HF 521 TABLE 1

Demographic and Clinical Characteristics of Persons With Heart Failure and Their Family Members (N = 117) Variable Age, y Charlson comorbidity index Gender Male Female Missing Education Vocational, high school, less College or higher Missing Ethnicity AA White Other Missing FM relationship to patient Adult child/ siblinga Othera Spouse/partner NYHA class Level II Level III

Patient

FM

55.9 (10.5) [28Y78 ]

52.1 (13.4) [19Y78] n = 114 0.9 (1.4) [0Y6]

3.1 (2.2) [1Y14]

74 (63.2) 43 (36.8)

20 (17.1) 95 (81.2) 2 (1.7)

61 (52.1)

59 (50.4)

56 (47.9)

56 (47.9) 2 (1.7)

68 (58.1) 49 (41.9)

68 (58.1) 46 (39.3) 1 (0.9) 2 (1.7)

NA 26 (22.2) 30 (25.6) 61 (52.1) NA 85 (72.6) 32 (27.4)

Data are presented as mean (SD) [minYmax] or n (%). Abbreviations: AA, African American; FM, family member; NA, not applicable; NYHA, New York Heart Association. Adult child/sibling and other were combined for the later analyses.

midpoint, indicating that, on average, the HF patient’s emotional HF QOL was in the moderate range (Table 2). Significant bivariate associations were found between patient characteristics and patient’s perceptions of family context variables. Older patients had lower perceived criticism scores (r = j0.19, P = .043); AA FMs scored lower on the HF knowledge test than white FMs did, with AA mean (SD) AHFKT scores of 63.42% (13.9%) versus white FM mean knowledge test scores of 73.69% (10.9%) (P G .001). Patients with higher education scored lower on the FAD global family functioning (r = j0.27, P G .01) and on the FAD communication scores (r = j0.27, P G .01), indicating better family functioning. There were also significant associations between the FM’s relationship to the patient and the patient’s perception of autonomy support (r = .21, P G .05), with lower perceived autonomy support when the FM was an adult child versus a spouse/partner. Mean FM’s HF knowledge was also slightly lower in the adult child and sibling FMs (63.31% [12.7%]) versus spouse/ partner FMs (71.73% [13.3%]; P = .001). In addition,

bivariate correlations among the patient’s perceptions of family context variables were also significant (Table 3). The significant correlations among the patient characteristics as noted above and between the patient characteristics and family context variables and among the family context variables (Table 3) confirmed the need for variable selection methods for reducing multicollinearity and optimizing each final regression model. Patient Perceptions on Family Context and Patient Depressive Symptoms As was expected, when considering all of the patient characteristics (block 1: age, gender, ethnicity, education, NYHA class, relationship to FM, and CCI) and patient’s perceptions of family context variables (block 2: FAD global family functioning, FAD problem solving, FAD communication, FEICS perceived criticism, autonomy support, and FM’s HF knowledge) together for building the regression models for patient depressive symptoms and emotional HF QOL, significant multicollinearity was noted by a condition index of 53.63 (much higher than 30) and 3 variables having VIFs greater than 2 and tolerance levels less than 0.5. Thus, for both the depression and HF QOL regression models, stepwise variable selection methods were used within each sequential block. Table 4 lists the complete regression results for depressive symptoms after each step of the stepwise variable selection methods within each blockV only age, ethnicity, and the CCI score were retained as significant covariates and global family functioning and FM HF knowledge were retained as the significant

TABLE 2 Descriptive Statistics of Patient’s Perceptions of Family Context, Depressive Symptoms, and Heart Failure Quality of Life Variables Overall Family Context Variables Autonomy support FAD global family functioning [% G2.0] FAD problem solving [% G2.2] FAD communication [% G2.2] FEICS perceived criticism Family member HF knowledge Beck Depression Inventory-II [% Q 14] MLHFQ total MLHFQ emotional MLHFQ physical

Mean (SD) [MinYMax] 5.85 (0.93) [3.00Y7.00] 1.96 (0.57) [1.00Y4.00] [46.5%] 1.97 (0.51) [1.00Y4.00] [78.9%] 2.18 (0.43) [1.22Y3.44] [46.5%] 1.86 (0.88) [1.00Y4.43] 67.78 (13.63) [33.33Y88.89] 13.13 (9.98) [0.0Y52.0] [39.5%] 50.34 (22.8) [2.0Y97.0] 9.65 (7.5) [0.0Y24.0] 22.17 (10.2) [0.0Y40.0]

Abbreviations: FAD, Family Assessment Device; FEICS, Family Emotional Involvement and Criticism Scale; HF, heart failure; MLHFQ, Minnesota Living With Heart Failure Questionnaire.

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522 Journal of Cardiovascular Nursing x November/December 2014 TABLE 3

Correlations Between Family Context Variables

Pearson’s Correlation (r) 1. 2. 3. 4. 5. 6.

Autonomy support FAD global family functioning FAD problem solving FAD communication FEICS perceived criticism Family member HF knowledge

1

2

3

4

5

6

1.000 j0.501a j0.407a j0.432a j0.536a 0.365a

1.000 0.824a 0.826a 0.421a j0.221b

1.000 0.789a 0.344a j0.144

1.000 0.380a j0.179

1.000 j0.230b

1.000

Abbreviations: FAD, Family Assessment Device; FEICS, Family Emotional Involvement and Criticism Scale; HF, heart failure. a P G .001. b P G .05.

family context variables. These methods alleviated the multicollinearity problems such that after step 5, before the addition of the interaction term, the condition index was 25.58 and all variables had VIF less than 1.37 and tolerance levels greater than 0.73. After step 5, it can be seen that younger patients, whites, and patients with higher (unhealthy) FAD global family functioning scores had a higher level of depressive symptoms (Table 4). Before the addition of the FAD global family functioning in step 4, in step 3, the CCI was a significant predictor of depressive symptoms, where patients with more comorbidities had higher depressive symptoms,

but this effect was no longer significant after the addition of the FAD global family functioning scores in step 4. As indicated in the Methods section, all possible bivariate interactions were investigated for each model to check the homogeneity of slopes assumptions for the patient characteristics in block 1 as covariates. For depressive symptoms, there was a significant interaction between ethnicity and FAD global family functioning (step 6 change R2 = 0.058, P = .001), indicating that ethnicity was a significant moderator of the association between global family functioning and depressive symptoms. The Figure illustrates this effect, where the

FIGURE. Moderation effects of ethnicity on the association between global family functioning and depression.

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Depression and Emotional QOL in Patients With HF 523 TABLE 4

Stepwise Linear Regression Model for Depressive symptoms

Variable Block 1 Step 1 (Constant) Age Step 2 (Constant) Age Ethnicity Step 3 (Constant) Age Ethnicity Charlson comorbidity Block 2 Step 4 (Constant) Age Ethnicity Charlson comorbidity FAD GFF Step 5 (Constant) Age Ethnicity Charlson comorbidity FAD GFF Family HF knowledge Block 3 Step 6 (Constant) Age Ethnicity Charlson comorbidity FAD GFF Family HF knowledge Ethnicity  FAD GFF

B

95% CI for B

28.434b j0.275a

18.610 j0.449

38.258 j0.102

31.445b j0.382b 6.987b

22.035 j0.556 3.320

40.856 j0.209 10.654

b

29.698 j0.393b 6.491b 0.830a c

13.153 j0.332b 6.334b 0.585 7.205b b

24.997 j0.340b 8.106b 0.513 6.389b j0.153c

b

37.413 j0.356b j8.718 0.439 1.673 j0.187a 8.946b

20.298 j0.564 2.853 0.060

2.451 j0.488 3.050 j0.117 4.366 10.706 j0.492 4.579 j0.176 3.532 j0.278

21.922 j0.502 j19.217 j0.219 j2.226 j0.309 3.658

39.098 j0.222 10.128 1.599

23.854 j0.176 9.619 1.286 10.044 39.288 j0.187 11.633 1.201 9.245 j0.027

52.903 j0.209 1.781 1.098 5.573 j0.066 14.234

$

F

Adjusted R2

$R2

F1,

109

= 9.874a

0.075

0.083a

F2,

108

= 12.671b

0.175

0.107b

F3,

107

= 10.249b

0.201

0.033c

F4,

106

= 15.762b

0.349

0.150b

F5,

105

= 14.349b

0.378

0.033a

F6,

104

= 15.001b

0.433

0.058b

j.288

j.401 .346

j.412 .321 .185

j.348 .314 .130 .395

j.356 .401 .114 .350 j.206

j.372 j.432 .098 .092 j.252 .925

Stepwise variable selection was used within each block. Variables considered in block 1: age, gender (0, male; 1, female), ethnicity (0, AA; 1, white), NYHA (0, class II; 1, class III), education (0, vocational, high school, or less; 1, college or higher), relationship (0, adult child, sibling, other; 1, spouse/partner), Charlson comorbidity index. Variables considered in block 2: FAD GFF, FAD Problem Solving, FAD Communication, FEICS Perceived Criticism, Family member HF knowledge, autonomy support. Variable entered in block 3: interaction between ethnicity and FAD GFF. Abbreviations: AA, African American; CI, confidence interval; FAD, Family Assessment Device; FEICS, Family Emotional Involvement and Criticism Scale; GFF, global family functioning; HF, heart failure; NYHA, New York Heart Association. a P G .01. b P G .001. c P G .05.

positive slope is much steeper for whites than for AAs. It should be noted that ethnicity and global family functioning are still both significant effects in the model, but after the addition of the interaction term in step 6, the main effects are nonsignificant, but the interaction term is significant. This is because of underlying mathematical associations and does not discount the individual effects. All effects are appropriately included in the final model.33 The combined effects of age, ethnicity, Carlson comorbidities, global family functioning, FM’s HF knowledge, and the moderation effect of ethnicity on global family functioning accounted for 43.3% of patient’s depressive symptom variance.

Patient Perceptions on Family Context and Patient Heart Failure Quality of Life As noted above, the same multicollinearity diagnostics were found for the regression models for the MLHFQ outcomes (total, physical, and emotional scores) because the same independent variables were under consideration. For the MLHFQ total and physical scores, no independent predictors were retained after adjusting for age using the stepwise variable selection process within each block, which was expected from an initial assessment using bivariate correlations. As such, no further regression results are presented for these two outcomes.

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524 Journal of Cardiovascular Nursing x November/December 2014 Table 5 lists the complete regression results for MLHFQ emotional scores after each step of the stepwise variable selection method within each blockVonly age and ethnicity were retained as significant covariates and global family functioning and autonomy support were retained as the significant family context variables. These methods minimized the multicollinearity problems such that after step 4, before the addition of the interaction term, the condition index was 28.34 and all variables had VIFs less than 1.37 and tolerance levels greater than 0.73. After step 4, it can be seen that younger patients, whites, and patients with higher (unhealthy) FAD global family functioning scores and lower (worse) autonomy support had higher (worse) MLHFQ emotional QOL (Table 5). After investigating all possible bivariate interactions to check the homogeneity of slopes assumptions for the patient characteristics in block 1 as covariates, for MLHFQ emotional scores, there was a significant interaction between ethnicity and FAD global family funcTABLE 5

tioning (step 5 change R2 = 0.046, P = .009), indicating that ethnicity was a significant moderator of the association between global family functioning and emotional QOL. Finally, the effects of age, ethnicity, global family functioning, autonomy support, and the moderation effect of ethnicity on global family functioning accounted for 28.9% of the patient’s emotional QOL variance.

Discussion Patient Perspectives on Family Context and Patient Depressive Symptoms In the multiple regression models, older age and higher levels of FM knowledge were significantly related to lower levels of depressive symptoms in patients with HF. Our finding of the relationship between older age and level of depressive symptoms is similar to that of other research findings that greater levels of depressive symptoms are more apparent in younger versus older

Stepwise Linear Regression Model for Heart Failure Quality of LifeYEmotional

Variable Block 1 Step 1 (Constant) Age Step 2 (Constant) Age Ethnicity Block 2 Step 3 (Constant) Age Ethnicity FAD GFF Step 4 (Constant) Age Ethnicity FAD GFF Autonomy support Block 3 Step 5 (Constant) Age Ethnicity FAD GFF Autonomy support Ethnicity  FAD GFF

B

95% CI for B

21.180b j0.206a b

13.810 j0.336

28.550 j0.076

22.487 j0.253b 3.033c

15.124 j0.388 0.164

29.850 j0.117 5.902

10.679a j0.213b 2.823c 4.986b

1.945 j0.340 0.160 2.689

19.412 j0.086 5.487 7.284

a

21.735 j0.203a 3.154c 3.697a j1.574c

7.790 j0.329 0.507 1.095 j3.135

35.679 j0.077 5.802 6.300 j0.013

28.984b j0.213b j8.177 0.593 j1.698a 5.887a

14.391 j0.335 j16.989 j2.833 j3.219 1.509

43.577 j0.090 0.635 4.019 j0.177 10.266

$

F

Adjusted R2

$R2

F1,

109

= 9.833a

0.074

0.083a

F2,

108

= 7.265b

0.102

0.036c

F3,

107

= 11.797b

0.227

0.130b

F4,

106

= 10.095b

0.249

0.027c

F5,

105

= 9.962b

0.289

0.046a

j.288

j.353 .200

j.297 .186 .364

j.284 .208 .270 j.193

j.297 j.540 .043 j.209 .811

Stepwise variable selection was used within each block. Variables considered in block 1: age, gender (0, male; 1, female), ethnicity (0, AA; 1, white), NYHA (0, class II; 1, class III), education (0, vocational, high school, or less; 1, college or higher), relationship (0, adult child, sibling, other; 1, spouse/partner), Charlson comorbidity index. Variables considered in block 2: FAD GFF, FAD Problem Solving, FAD Communication, FEICS Perceived Criticism, Family member HF knowledge, autonomy support. Variable entered in block 3: interaction between ethnicity and FAD GFF. Abbreviations: AA, African American; CI, confidence interval; FAD, Family Assessment Device; FEICS, Family Emotional Involvement and Criticism Scale; GFF, global family functioning; HF, heart failure; NYHA, New York Heart Association. a P G .01. b P G .001. c P G .05.

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Depression and Emotional QOL in Patients With HF 525

adults with HF.34 A possible reason for this finding in our study could be related to the developmental phase of life of the participants. For example, younger patients may still be of working age but have a lower functional capacity, which interferes with the activities of daily living that would be normal for their specific age group. The finding regarding the relationship between higher levels of FM knowledge of HF and lower levels of depressive symptoms may be explained in a couple of ways. First, higher levels of FM knowledge may lead to a greater understanding of HF and the HF care regimen, which may lead to a greater level of involvement in HF care management as well as perceived control by the patient. Second, the greater level of perceived control by the FMs may increase their ability to provide a higher level of support to the patient with HF. Although the research is limited concerning the association of FM knowledge and level of depressive symptoms in chronically ill patients, our findings were consistent with those of Sebern and Woda,35 who found that higher levels of depressive symptoms in patients with HF were associated with lower levels of FM knowledge and ineffective family functioning.35 Increased levels of depressive symptoms in patients with HF are related to a decrease in their ability to care for their condition of HF.36,37 Therefore, assessing patient characteristics (ie, age and ethnicity) and family context variables such as family functioning and FM knowledge is important to consider when developing interventions to improve depressive symptom outcomes in patients with HF. For example, if family functioning is not optimal, assisting the patient to identify and seek other sources of assistance and support may be useful as well as helping them understand how to cope when the family is disrupted. A serendipitous finding was that patients’ depressive symptoms might differ by ethnicity based on the level of family functioning. In this study, AAs’ level of depressive symptoms did not significantly change in the presence of ineffective family functioning. In contrast, whites appeared to be more sensitive to poor family functioning (as global family functioning worsened, depressive symptoms increased). This finding is contradictory to the literature that reports that effective family functioning decreases the risk of AA suicide, depressive symptoms, and behavioral problems.13,38 A possible explanation is that our sample was composed of chronically ill patients with HF and their relationships may differ from studies of family functioning in the general population. Another possible explanation may be that the cultural norms for AAs in the southeast region of the United States where this study was conducted were composed of larger support systems such as extended families, religious faith groups within churches or associations, and larger community affiliations. Therefore, AAs with HF in this study may have greater resiliency and other

avenues for support when family functioning was low; however, further study is needed to verify both of these suppositions.

Patient Perspectives on Family Context and Patient Heart Failure Quality of LifeYEmotional In the multiple regression models, older age and higher levels of family functioning and autonomy support were significantly related to a greater perceived QOL in patients with HF. The relationship of age to greater perceived QOL is similar to that of other research findings that have reported greater perceived QOL in older versus younger patients with HF.39,40 Higher levels of family functioning and autonomy support were independent predictors of better emotional QOL for patients with HF in this study. This was an expected finding because autonomy support refers to the ability of an FM to listen to the patient’s perspective, encourage self-initiation, offer choice, provide alternatives, minimize pressure, and accept the healthcare decisions of the patient with HF.24,41 Similarly, the opposite of autonomy support is perceived criticism, which can be described as a controlling behavior by an FM, such as negative communication that may occur in an effort to control the behavior of the patient (ie, the performance of a patient’s care behaviors).20,24 Perceived criticism was less influential on QOL than autonomy support in this study. Autonomy support has been studied with a variety of populations such as healthcare providers and FMs of patients with chronic illnesses. However, much of the current literature has yielded mixed results based on the type of chronic illnesses studied and who provided the autonomy support (ie, healthcare provider or FM). For example, Holm and colleagues6 found that patients with chronic obstructive pulmonary disease who reported lower levels of autonomy support and higher levels of perceived criticism by FMs exhibited a decrease in health-related QOL and an increase in physiological symptoms.6 Gibson and colleagues42 found that autonomy support by healthcare providers was not correlated with QOL in patients with asthma. Karlsen and colleagues43 found that less autonomy support by FMs led to increased self-blaming and decreased coping in individuals with type 2 diabetes. These findings revealed that when the patients with HF perceived a higher level of family functioning and greater autonomy support, their reported QOL was improved. This was not surprising considering the focus of the items, which reflected how much support patients received in managing their illness and how burdensome they may or may not have felt to their FM. These findings suggest that clinicians need to assist FMs

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526 Journal of Cardiovascular Nursing x November/December 2014

What’s New and Important h More effective global family functioning and higher levels of FM knowledge were associated with decreased depressive symptoms in patients with HF. h Patients with HF reported better emotional QOL in the context of better family functioning and more autonomy support. h Decreased family functioning had less negative effects on depressive symptoms in AAs versus whites.

support and context should be viewed at risk for greater depressive symptoms and lower QOL. The clinical significance of these results directs practitioners to better understand the family context and its effect on psychosocial outcomes and to incorporate and evaluate culturally sensitive, family-focused interventions geared toward decreasing depressive symptoms and increasing QOL for patients with HF. Acknowledgments

in understanding the importance of supportive communication with their loved one who has HF. These analyses showed that ethnicity and level of family functioning moderated the emotional aspect of QOL for patients with HF. The level of family functioning of AAs with HF did not significantly change their emotional QOL, whereas whites with HF who reported lower levels of family functioning also reported lower levels of emotional QOL. There is a paucity of literature concerning the effect of ethnicity and family functioning on emotional QOL of patients with HF. However, this finding is similar to and overlaps with the results related to depressive symptoms, and AAs with HF in this study may have greater resiliency and other avenues for emotional support when family functioning was low. Again, further study is needed.

Limitations Several limitations of our study should be acknowledged. There may be other important family and support variables such as family cohesion, family conflict, or social support from a wider network that we did not measure. Such variables could help illuminate the specific family and social context variables that are most influential in psychological outcomes for patients with HF in general as well as by ethnicity. Moreover, the rigorous inclusion and exclusion criteria were selected to remove variation within the outcome variables of the larger intervention study and may limit generalizability of these findings. Nevertheless the significant associations between family context variables and both depressive symptoms and QOL were consistent and fairly strong.

Conclusion Our findings suggests that age, ethnicity, family functioning, autonomy support, and FM knowledge of HF may be important influences on the levels of depressive symptoms and the emotional aspect of QOL in this diverse sample of patients with HF. The results indicate that further work concerning family context variables on psychosocial outcomes in patients with HF is necessary. An important finding is that younger patients and those with poor perceptions of their family

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Family context influences psychological outcomes of depressive symptoms and emotional quality of life in patients with heart failure.

Although family influences in heart failure (HF) care are considered important, little evidence is available regarding relationships between the famil...
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